Appropriateness of technology interventions in maternity systems

When we want to know about the safe and effective use of amedication, we can choose to find information from sourcessuch as the British National Formulary, the Food and DrugAdministration or the Medicines and Healthcare ProductsRegulatory Agency but we do not have the same level ofimmediate access to evidence for the safe and effective use ofother, common or routinely used, birth technologies. I wouldstrongly argue that this situation must change and, as themarket becomes flooded with newer and more sophisticatedtechnologies, we need a much more robust and transparentmechanism to aid us in our everyday decision-making. Forexample, on 7 May 2012, I was fascinated to read about newresearch emanating from Erasmus MC, Embryos floating ini-space, and the application of new 3D hologram technologythat enables scientists to see the minutest aspects of early fetaldevelopment. For me, this is another example of our needto see what is hidden and the power of technology to showus what we cannot see with our human eye (occularcentrismdriving us towards the development of newer and morepowerful visual technologies).There is no European guidance on the minimum ormaximum application of technology to the ‘normal’ or‘higher-risk’ pregnancy, and no agreed classification of thetechnologies currently available. It is over 25 years since theconsensus conference on the appropriate use of technologyby the WHO in 1985, from which targets for caesareanbirth rates (10 to 15%) emerged. Today, modern womenwho are pregnant use Twitter, Facebook, smartphones,pregnancy apps, google analytics and online supportsystems, such as Netmums, to manage pregnancy, preparefor birth and adjust to motherhood. When they enter thehealth service, they are subject to a wide range of overt andcovert birth technologies that are applied routinely. In theantenatal period, these include drawing blood for a rangeof purposes, electronic record-keeping, anomaly scans andfetal monitoring. In the intrapartum period, even births thatare termed ‘normal’ are supported by a range of ‘invisibletechnologies’ from simple administration proceduresto techniques and pharmacological interventions to aideffective pain relief in labour.Defining and classifying the technological applicationsavailable is a complex process. Sinclair (2010) offered acrude classification of ‘low technology’ mechanical devices,such as the pinard stethoscope for fetal monitoring, thatdemand skill and expertise in interpretation, and hightechnology devices characterised by their electronic orartificial intelligence, such as the cardiotocograph machineand dinomapp classified as monitoring devices and theIVAC and Graseby devices classified as interventioncontrolling devices.The majority of women who give birth in Europefollow a similar antenatal care pathway involving the useof technology for pregnancy confirmation, pregnancymonitoring, fetal surveillance and labour management. Therecent EUROCAT (2010) Special report: prenatal screeningpolicies in Europe 2010 demonstrates the wide variation inpolicy, practice, legal standing and availability of a rangeof technologies for fetal screening, including the use ofultrasound, biochemical analyses, triple tests and abortion.However, there is no discernible distinction between ‘lowrisk’and ‘high risk’ women. More invasive and/or prolongedtechnological procedures and devices are used for womendeemed ‘higher risk’ due to chronic conditions, such asepilepsy or diabetes. In many countries, such women aresubject to intensive monitoring leading to a ‘domino effect’that’s more likely to end in higher risk of caesarean sectionand instrumental birth.Women in the higher risk categories are more likely to havean increased risk of carrying a fetus with an anomaly andface the abortion decision. European data for 2006 to 2010(EUROCAT, 2010) demonstrates the detection of 92,702anomalies in utero of which termination of pregnancy forfetal anomaly (TOPFA) was carried out on 15,670 (rate of16.9%). However, newer technological procedures offer theoption of fetal surgery for babies who have a wide range ofconditions such as cleft lip and palate, spina bifida and heartdefects such as ventricular septal defect and patent ductusarteriosus. These techniques are becoming more successful,but they remain complex and expensive, and they arenot always available. The US pioneered fetal surgery butEurope is developing its own body of expertise and severalrandomised controlled trials have taken place. The potentialfor technology to reduce the impact of birth defects is onearea that requires careful evaluation. However, technologyacceptance requires multi-faceted approaches to producethe right type of evidence and collective consciousness tointerpret and transfer the meaning into everyday life. Forexample, the growing problem facing the population ofwomen who conceive while on prescribed lifelong medicationis what range and level of birth technology ‘needs to be madeavailable for whom’ and ‘in what circumstances’.